Aggressive Periodontitis Patient Information:Rose Smith is a 19year old female, ethnicity- African American, DOB: 7/ 7/1992. Reason for Visit: She is a patient today for dental hygiene care and she complains that she has two loose teeth.Dental History:Yes: Loose teeth. Patient noticed since 2007- mandibular first molars and mandibular incisors. Last dental exam: October of 2010.
Previous Dentist: Pure Gold Professionals.
Last x-rays: October 2010. 18 FMX
Last cleaning: In April of 2010- regular cleaning.Medial History: Cardiovascular System: No past or present history of any diseases.
Head/neck problems: the patient marked yes to visual impairment-she wears glasses since she was 7years old; she is nearsighted.
Social life- no past or present history of social life problems.
Neuromuscular System/CNS: No past or present history of any diseases.
Hemo/Endo/Immune Disorders: frequent canker sore on lower lip and apthous ulcers since 2009 last breakout 5/2010.
Psychological and behavioral problems: No past or present history of any problems. Childhood vaccinations and Hepatitis B vaccination series were completed in 2001.
Family History- no family history of any conditions
Hospitalizations: noneMedications:Medication Name: Abreva (Docosanol)Dose: apply 5x a day to infected areaPeriod of time taken: as neededLast taken: 5/2010Taken for: cold sores/ herpes simplex of the lips (type1)Dental Implications: No significant effects or complications reported to require special precautionsDental contraindicatons: no information avalible to require special precautions Assessments:
Maximum opening: 42mm.
Salivary flow is adequate.
Gingival description: Free gingiva is generalized pink, firm fills the embrasure with localized erythema b/w 23-26, and around 31; the interdental papilla is bulbous; and shiny. Attached gingiva is generalized pink with melanin pigmentations, firmly attached to the bone and stippled w/ localized erythema, loss of stippling and glossy b/w 23 and 26 and around 31.
Angels class: Bilateral Class I normal occlusion.
Facial profile: Mesognathic.
MBI 11%.BOP 19%.
Generalized probing depths of 3-4mm and localized 5-6mm.
Restorative findings: Occlusal Amalgam #3, 14, 19, 30, & 31.
Recession: 22-2mm, 23-2mm, 24-4mm, 25-4mm, 26-2mm, 27-2mm.
Furcations: Class II #14 & 19, Class III on #3 & 30.
Mobility: (+) #7-9, Class II# 3, 19, 23, 26, & 30. Class III on #24-25.
Fremitus: +7-10.
Mucogingival defects on 24, 25, and 26.
Calculus code: light/medPI 22%.
DDS exam:
Missing teeth: 1 never developed, 16, 17, and 32 impacted.
Restorations- no open margins, overhangs.
Possible areas of decay: none
No radiolucency at apices
No intrinsic absorption noted
No extrinsic absorption noted
No dilaceration of roots noted
Root resoption-#3, 14, and 19.
No atypical findings such as attrition, erosion, enamel pear, super numary tooth.
General osseous: no radiolucent/radiopaque lesions or foreign objects Referral
DDS: Extraction #24-25
Periodontist: Evaluate #3, 14, 19, and 30.
2nd check-in
Periodontal Interpretation:
Quality of radiographs- incorrect vertical angulation
Trabecular pattern- consistent throughout
Lamina dura- not present
Alveolar crest is generalized 1-2mm from the CEJ with localized 5-6mm.
Vertical bone loss M-2, D-3,D-14, D-19, M-23, M & D- 24-25, M-26, and M & D-31.
PDL inconsistent
Interadicular radiolucency- furcations on 3 and 30.
Calculus noted on the M/D of #31
ADA case type II with localized IV.
AAP: Genralized slight chronic periodontitis with localized severe periodontitis due to plaque and calculus.
MVC calculus Code: Light/Med
Critical Thinking:
Chief complaint: Pt. is concerned with two loose teeth.
Medical History/ Systemic Health: Herpes simplex (type1)
Oral Risk Factors: to avoid spread of viral infection avoid treatment when pt. has a lesion
Dental Health Diag.: Perio, Carries and Oral Hygiene = Uncontrolled
Influencing cultural and social factors: Pt. is young and dose not quite grasp the concept of the importance of proper oral health
Oral Health Belief model: Transtheoretical Modle and stages of change: Pre-contimplation stage: pt. has little or no intrest and no intention of changing behavior
Recommended OHI: Soft bristle toothbrush using Bass method 2x a day, Floss 1x a day and demonstrate "C" shape flossing technique.
Instrument selection: Sickles, gracey, and universal.
Anesthesia /rational: yes, 2 % lidocaine with vasopressor to maintain patient comfort due to pocket depths. Maxilla= PSA & GP (Concerned w/ probing depths M-#2 & D-#3, D-#14 & M-#15) Mandible= Gow Gates (Concerned w/ probing depths D-#19. #23-26, #30, M-#31)
Reevaluations: any herpe simplex sores that may be present
Anticipated outcomes: maintain bone level, reduce PI by 5% and BOP by 5% also reduce 4mm -3mm, 5mm-4mm and 6mm-5mm pocket depths.
Referrals: Periodontist: Extraction #24-25 and Evaluate #3, 14, 19, and 30.
Recall interval: 3 month recare
Rational: To maintain Oral hygiene and evaluate bone loss.
Treatment Planning:
Appt. 1
X-ray check
4 BWX
Assessments
DDS exam
Second check in
Appt. 2
PI/OHI
URQ w/ anes. (PSA & GP)
LRQ w/ anes. (Gow Gates)
Chlorhexidine # M-2, D-3, M & D-25, M-26, and M & D-31.
Fluoride varnish treatment
Appointment 1: S: Patient states she “is concerned with two loose teeth”. O: RMH, B/P: 116/76, P: 74, R: 16. Extra oral findings: None, Intra oral findings: None. Maximum opening: 42mm. Salivary flow is adequate. Gingival description: Free gingiva is generalized pink, firm fills the embrasure with localized erythema b/w 23-26, and around 31; the interdental papilla is bulbous; and shiny. Attached gingiva is generalized pink with melanin pigmentations, firmly attached to the bone and stippled w/ localized erythema, loss of stippling and glossy b/w 23 and 26 and around 31. Angels class: bilateral Class I normal occlusion. Facial profile: Mesognathic. MBI :11%. BOP: 19%. Generalized probing depths of 1-2mm and localized 5-6mm. Restorative findings: Occlusal Amalgam #3, 14, 19, 30, & 31. Recession: 22-2mm, 23-2mm, 24-4mm, 25-4mm, 26-2mm, 27-2mm.Furcations: Class II #14 & 19, Class III on #3 & 30. Mobility: (+) #7-9, Class II# 3, 19, 23, 26, & 30. Class III on #24-25. Fremitus: +7-10. Mucogingival defects on 24, 25, and 26. A: ASA I, ADA case type II with localized IV. AAP: Generalized slight chronic periodontitis with localized severe periodontitis due to plaque and calculus. MVC calculus Code: Light. P: X-ray check, completed BWX (4 films), completed assessments, DDS exam and 2nd check-in. N.V: PI, OHI, Scale URQ and LRQ with anesthesia, Chlorhexidine treatment and Fluoride varnish.
------AdamsBaezaBobovaCadena #2012----- Appointment 2: S: Patient states she “is concerned with two loose teeth”. O: RMH-no changes, B/P: 116/74, P: 72, R: 16. E & I exam: no findings. A: ASA I, ADA case type II with localized IV. AAP: Generalized slight chronic periodontitis with localized severe periodontitis due to plaque and calculus. MVC calculus Code: Light. P: PI-22%, OHI-demonstrated Bass method and “C” shape flossing technique, Scaled URQ & LRQ with anesthesia, Chlorhexidine treatment # 2-3, 25-26, and 31, and Fluoride varnish. Administered PSA, GP, and gow gates on the patient’s right side, used 2% lidocaine with vasopressor at a total amount of 3.15 ml. Applied 5% sodium fluoride varnish. Advised patient to not eat or drink for 30 minutes, avoid gum, hard or sticky food & candy for 4 hours.Patient tolerated the procedure well and was dismissed from clinic in good condition. N.V: Scale ULQ & LLQ, Chlorhexidine treatment, and fluoride varnish. ------AdamsBaezaBobovaCadena #2012-----
Appointment 3: S: Patient states she “is concerned with two loose teeth”. O: RMH-no changes, B/P: 114/74, P: 80, R: 17. E & I exam: no findings. A: ASA I, ADA case type II with localized IV. AAP: Generalized slight chronic periodontitis with localized severe periodontitis due to plaque and calculus. MVC calculus Code: Light. P: Scaled ULQ & LLQ with anesthesia, Chlorhexidine treatment # 14, 19, & 23-24, and Fluoride varnish. Administered PSA, GP, and gow gates on the patient’s left side, used 2% lidocaine with vasopressor at a total amount of 3.15 ml. Applied 5% sodium fluoride varnish. Advised patient to not eat or drink for 30 minutes, avoid gum, hard or sticky food & candy for 4 hours.Patient tolerated the procedure well and was dismissed from clinic in good condition. N.V: 3 month recare ------AdamsBaezaBobovaCadena #2012-----
Reference Carranza, F., Klokkevold, P., Newman, M., & Takei, H. (2006). Carranza's clinical periodontology. (10 ed., pp. 506-511). St. Louis, MO: Saunders Elsevier.
Patient Information:Rose Smith is a 19year old female, ethnicity- African American, DOB: 7/ 7/1992. Reason for Visit: She is a patient today for dental hygiene care and she complains that she has two loose teeth.Dental History:Yes: Loose teeth. Patient noticed since 2007- mandibular first molars and mandibular incisors.
Last dental exam: October of 2010.
Previous Dentist: Pure Gold Professionals.
Last x-rays: October 2010. 18 FMX
Last cleaning: In April of 2010- regular cleaning.Medial History:
Cardiovascular System: No past or present history of any diseases.
Head/neck problems: the patient marked yes to visual impairment-she wears glasses since she was 7years old; she is nearsighted.
Social life- no past or present history of social life problems.
Neuromuscular System/CNS: No past or present history of any diseases.
Hemo/Endo/Immune Disorders: frequent canker sore on lower lip and apthous ulcers since 2009 last breakout 5/2010.
Psychological and behavioral problems: No past or present history of any problems.
Childhood vaccinations and Hepatitis B vaccination series were completed in 2001.
Family History- no family history of any conditions
Hospitalizations: noneMedications:Medication Name: Abreva (Docosanol)Dose: apply 5x a day to infected areaPeriod of time taken: as neededLast taken: 5/2010Taken for: cold sores/ herpes simplex of the lips (type1)Dental Implications: No significant effects or complications reported to require special precautionsDental contraindicatons: no information avalible to require special precautions
Assessments:
Maximum opening: 42mm.
Salivary flow is adequate.
Gingival description: Free gingiva is generalized pink, firm fills the embrasure with localized erythema b/w 23-26, and around 31; the interdental papilla is bulbous; and shiny. Attached gingiva is generalized pink with melanin pigmentations, firmly attached to the bone and stippled w/ localized erythema, loss of stippling and glossy b/w 23 and 26 and around 31.
Angels class: Bilateral Class I normal occlusion.
Facial profile: Mesognathic.
MBI 11%.BOP 19%.
Generalized probing depths of 3-4mm and localized 5-6mm.
Restorative findings: Occlusal Amalgam #3, 14, 19, 30, & 31.
Recession: 22-2mm, 23-2mm, 24-4mm, 25-4mm, 26-2mm, 27-2mm.
Furcations: Class II #14 & 19, Class III on #3 & 30.
Mobility: (+) #7-9, Class II# 3, 19, 23, 26, & 30. Class III on #24-25.
Fremitus: +7-10.
Mucogingival defects on 24, 25, and 26.
Calculus code: light/medPI 22%.
DDS exam:
Missing teeth: 1 never developed, 16, 17, and 32 impacted.
Restorations- no open margins, overhangs.
Possible areas of decay: none
No radiolucency at apices
No intrinsic absorption noted
No extrinsic absorption noted
No dilaceration of roots noted
Root resoption-#3, 14, and 19.
No atypical findings such as attrition, erosion, enamel pear, super numary tooth.
General osseous: no radiolucent/radiopaque lesions or foreign objects
Referral
DDS: Extraction #24-25
Periodontist: Evaluate #3, 14, 19, and 30.
2nd check-in
Periodontal Interpretation:
Quality of radiographs- incorrect vertical angulation
Trabecular pattern- consistent throughout
Lamina dura- not present
Alveolar crest is generalized 1-2mm from the CEJ with localized 5-6mm.
Vertical bone loss M-2, D-3,D-14, D-19, M-23, M & D- 24-25, M-26, and M & D-31.
PDL inconsistent
Interadicular radiolucency- furcations on 3 and 30.
Calculus noted on the M/D of #31
ADA case type II with localized IV.
AAP: Genralized slight chronic periodontitis with localized severe periodontitis due to plaque and calculus.
MVC calculus Code: Light/Med
Critical Thinking:
Chief complaint: Pt. is concerned with two loose teeth.
Medical History/ Systemic Health: Herpes simplex (type1)
Oral Risk Factors: to avoid spread of viral infection avoid treatment when pt. has a lesion
Dental Health Diag.: Perio, Carries and Oral Hygiene = Uncontrolled
Influencing cultural and social factors: Pt. is young and dose not quite grasp the concept of the importance of proper oral health
Oral Health Belief model: Transtheoretical Modle and stages of change: Pre-contimplation stage: pt. has little or no intrest and no intention of changing behavior
Recommended OHI: Soft bristle toothbrush using Bass method 2x a day, Floss 1x a day and demonstrate "C" shape flossing technique.
Instrument selection: Sickles, gracey, and universal.
Anesthesia /rational: yes, 2 % lidocaine with vasopressor to maintain patient comfort due to pocket depths. Maxilla= PSA & GP (Concerned w/ probing depths M-#2 & D-#3, D-#14 & M-#15) Mandible= Gow Gates (Concerned w/ probing depths D-#19. #23-26, #30, M-#31)
Reevaluations: any herpe simplex sores that may be present
Anticipated outcomes: maintain bone level, reduce PI by 5% and BOP by 5% also reduce 4mm -3mm, 5mm-4mm and 6mm-5mm pocket depths.
Referrals: Periodontist: Extraction #24-25 and Evaluate #3, 14, 19, and 30.
Recall interval: 3 month recare
Rational: To maintain Oral hygiene and evaluate bone loss.
Treatment Planning:
Appt. 1
X-ray check
4 BWX
Assessments
DDS exam
Second check in
Appt. 2
PI/OHI
URQ w/ anes. (PSA & GP)
LRQ w/ anes. (Gow Gates)
Chlorhexidine # M-2, D-3, M & D-25, M-26, and M & D-31.
Fluoride varnish treatment
Appt. 3
ULQ w/ anes. (PSA & GP)
LLQ w/ anes. (Gow Gates)
Chlorhexidine #D-14, D-19, M-23, and M & D- 24.
Fluoride varnish treatment
Appt. 4
4 month recare
SOAP Notes:
Appointment 1:
S: Patient states she “is concerned with two loose teeth”.
O: RMH, B/P: 116/76, P: 74, R: 16. Extra oral findings: None, Intra oral findings: None. Maximum opening: 42mm. Salivary flow is adequate. Gingival description: Free gingiva is generalized pink, firm fills the embrasure with localized erythema b/w 23-26, and around 31; the interdental papilla is bulbous; and shiny. Attached gingiva is generalized pink with melanin pigmentations, firmly attached to the bone and stippled w/ localized erythema, loss of stippling and glossy b/w 23 and 26 and around 31. Angels class: bilateral Class I normal occlusion. Facial profile: Mesognathic. MBI :11%. BOP: 19%. Generalized probing depths of 1-2mm and localized 5-6mm. Restorative findings: Occlusal Amalgam #3, 14, 19, 30, & 31. Recession: 22-2mm, 23-2mm, 24-4mm, 25-4mm, 26-2mm, 27-2mm.Furcations: Class II #14 & 19, Class III on #3 & 30. Mobility: (+) #7-9, Class II# 3, 19, 23, 26, & 30. Class III on #24-25. Fremitus: +7-10. Mucogingival defects on 24, 25, and 26.
A: ASA I, ADA case type II with localized IV. AAP: Generalized slight chronic periodontitis with localized severe periodontitis due to plaque and calculus. MVC calculus Code: Light.
P: X-ray check, completed BWX (4 films), completed assessments, DDS exam and 2nd check-in.
N.V: PI, OHI, Scale URQ and LRQ with anesthesia, Chlorhexidine treatment and Fluoride varnish.
------AdamsBaezaBobovaCadena #2012-----
Appointment 2:
S: Patient states she “is concerned with two loose teeth”.
O: RMH-no changes, B/P: 116/74, P: 72, R: 16. E & I exam: no findings.
A: ASA I, ADA case type II with localized IV. AAP: Generalized slight chronic periodontitis with localized severe periodontitis due to plaque and calculus. MVC calculus Code: Light.
P: PI-22%, OHI-demonstrated Bass method and “C” shape flossing technique, Scaled URQ & LRQ with anesthesia, Chlorhexidine treatment # 2-3, 25-26, and 31, and Fluoride varnish. Administered PSA, GP, and gow gates on the patient’s right side, used 2% lidocaine with vasopressor at a total amount of 3.15 ml. Applied 5% sodium fluoride varnish. Advised patient to not eat or drink for 30 minutes, avoid gum, hard or sticky food & candy for 4 hours.Patient tolerated the procedure well and was dismissed from clinic in good condition.
N.V: Scale ULQ & LLQ, Chlorhexidine treatment, and fluoride varnish.
------AdamsBaezaBobovaCadena #2012-----
Appointment 3:
S: Patient states she “is concerned with two loose teeth”.
O: RMH-no changes, B/P: 114/74, P: 80, R: 17. E & I exam: no findings.
A: ASA I, ADA case type II with localized IV. AAP: Generalized slight chronic periodontitis with localized severe periodontitis due to plaque and calculus. MVC calculus Code: Light.
P: Scaled ULQ & LLQ with anesthesia, Chlorhexidine treatment # 14, 19, & 23-24, and Fluoride varnish. Administered PSA, GP, and gow gates on the patient’s left side, used 2% lidocaine with vasopressor at a total amount of 3.15 ml. Applied 5% sodium fluoride varnish. Advised patient to not eat or drink for 30 minutes, avoid gum, hard or sticky food & candy for 4 hours.Patient tolerated the procedure well and was dismissed from clinic in good condition.
N.V: 3 month recare
------AdamsBaezaBobovaCadena #2012-----
Reference
Carranza, F., Klokkevold, P., Newman, M., & Takei, H. (2006). Carranza's clinical periodontology. (10 ed., pp. 506-511). St. Louis, MO: Saunders
Elsevier.